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4th Year Cardiology > Heart failure + Hypertension > Flashcards

Heart failure + Hypertension Flashcards

1
Q

Pathophysiology of congestive heart failure

A
  • In a normal heart, increased ventricular filling results in increased contraction via the Frank-Starling law → increased cardiac output
  • In patients with heart failure, this mechanism fails
  • As the heart continues to fail → compensatory mechanisms are activated, including an increase in heart rate, catecholamine release and RAAS activation
  • These mechanisms are useful in the initial period but are usually overexpressed, thus instigating a vicious cycle
  • Medications such as ACE inhibitors aim to target these compensatory pathways
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2
Q

Common causes of congestive cardiac heart failure

A
  • Ischaemic heart disease
  • Hypertension
  • Valvular disease
  • Atrial fibrillation
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3
Q

Symptoms of left sided heart failure

A
  • Dyspnoea: particularly exertional
  • Orthopnoea and paroxysmal nocturnal dyspnoea
  • Fatigue and weakness
  • Cough with pink, frothy sputum
  • Cardiogenic wheeze
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4
Q

Signs of left sided heart failure

A
  • Tachypnoea and tachycardia
  • Cool peripheries
  • Peripheral or central cyanosis
  • Displaced apex beat
  • Stony dull percussion: if an effusion is present
  • Crackles on auscultation: coarse bi-basal crackles
  • Third heart sound (S3)
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5
Q

Symptoms of right sided heart failure

A
  • Swelling in the legs
  • Distended abdomen
  • Fatigue and weakness
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6
Q

Signs of right sided heart failure

A
  • Raised JVP
  • Peripheral pitting oedema
  • Hepatosplenomegaly
  • Ascites
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7
Q

Which criteria is used to classify heart failure?

A

The New York Heart Association (NYHA) classification system

Class 1:

  • no limitation of physical activity
  • ordinary physical activity does not cause symptoms (fatigue, palpitation, dyspnoea)

Class 2:

  • slight limitation of physical activity
  • ordinary physical activity causes symptoms

Class 3:

  • marked limitation of physical activity
  • less than ordinary physical activity causes symptoms

Class 4:

  • all physical activity causes discomfort
  • symptoms at rest
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8
Q

Investigations for heart failure

A
  • Bedside
    • ECG: broad QRS and evidence of LVH (high amplitude)
  • Bloods
    • NT-proBNP:
      • >400pmol/L suggests HF and requires transthoracic ECHO within 6 weeks
      • >2000pmol/L requires urgent transthoracic ECHO within 2 weeks
      • Acute heart failure: urgent ECHO (usually within 48 hours)
    • FBC: anaemia causes high output failure
    • U&Es: CKD can cause heart failure
    • TFTs: hyperthyroidism can cause high output failure
  • Imaging
    • Transthoracic ECHO: assess left ventricular ejection fraction, diastolic function
    • CXR: assess heart size (PA film) and evidence of pulmonary congestion
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9
Q

Signs of heart failure on X-ray

A
  • A - Alveloar oedema (batwing opacities)
  • B - Kerley B lines
  • C - Cardiomegaly
  • D - Dilated upper lobe vessels
  • E - Pleural Effusion
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10
Q

Management of congestive heart failure

A
  • 1st line: Beta-blocker and ACE inhibitor: start one drug at a time. Beta-blockers (e.g. bisoprolol) and ACE inhibitors (e.g. ramipril) have been shown to reduce mortality
  • 2nd line: Aldosterone antagonist (e.g. spironolactone)
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11
Q

Congestive cardiac failure

Despite bisoprolol, ramirpil and spironolactone, the patient is breathless at rest

What is the most appropriate next step?

A
  • Cardiac resynchronisation therapy (CRT) or implantable cardioverter-defibrillator (ICD)
    • (CRT involves biventricular pacing and forces both ventricles to contract in synchrony, thereby improving cardiac output)
    • (An ICD is able to perform cardioversion, defibrillation and, in some cases, pacing)
    • CRT or an ICD is generally indicated in: symptomatic patients with an ECG indicating ventricular dyssynchrony (e.g. QRS >120ms) AND LVEF <35%
  • Digoxin: an alternative option, particularly for patients with atrial fibrillation and heart failure due to its inotropic effects. It does not improve prognosis in patients with heart failure
  • Ivabradine: an alternative option if HR >75 bpm and LVEF <35%, and the patient is already on suitable medication (e.g. bisoprolol, ramipril and spironolactone)
  • Sacubitril valsartan: if LVEF <35% (will replace ACEi)
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12
Q

Adjunctive management of congestive heart failure

A
  • Fluid restriction: usually limited to <1.5L/day, but varies between patients
  • Loop diuretic (e.g. furosemide): confers symptomatic relief of fluid overload but no improvement in prognosis
  • Annual influenza vaccine and one-off pneumococcal vaccine
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13
Q

Acute heart failure - key concern

A

Acute heart failure can cause significant pulmonary oedema and respiratory failure

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14
Q

Management of acute heart failure

A

Stabilise

  • Oxygen: is SpO2 <94% or type 1 respiratory failure
  • Fluid restriction: 1.5L
  • IV diuretic: furosemide infusion
  • Monitor daily weights and urine output

Consider

  • IV nitrates: if evidence of HTN or myocardial ischaemia; reduces preload
  • Inotropes (eg dobutamine): if evidence of haemodynamic instability; improves ejection fraction
  • Ventilation:
    • CPAP: for type 1 respiratory failure
    • Mechanical ventilation if above fail
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15
Q

Pathophysiology of essential hypertension

A

Cardiac output x peripheral resistance = Mean arterial pressure

Cardiac output = Stroke volume + Heart rate

Peripheral resistance = Vascular tone (eg activation of RAAS) + Vascular structure (eg atherosclerosis)

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16
Q

Primary hypertension

A
  • 90-95% of cases of hypertension
  • Essential hypertension, no known underlying cause
17
Q

Causes of secondary hypertension

A
  • Renal disease
    • Glomerulonephritis
    • Polycystic kidney disease
    • Chronic kidney disease
  • Endocrine disorders
    • Primary hyperaldosteronism
    • Pheochromocytma
    • Cushing’s syndrome
    • Hyperthyroidism
    • Acromegaly
  • Medication
    • Glucocorticoids
    • Atypical antipsychotics
    • Combined oral contraceptive pill
  • Pregnancy
18
Q

Main complications of persistent hypertension

A
  • Brain
    • Cerebrovascular accident
    • Hypertensive encephalopathy
  • Retina
    • Hypertensive retinopathy
  • Heart
    • Myocardial infarction
    • Hypertensive cardiomyopathy
  • Kidneys
    • Hypertensive nephropathy
  • Hyperglycaemia
19
Q

Primary investigations for hypertension

A
  • Blood pressure
    • If ≥140/90mmHg, take a second reading
  • ABPM
    • BP measured over a 24 hour period
    • Offer to all patients with clinic BP 140/90 - 180/120

Investigations to consider:

  • HBPM
    • If ABPM not appropriate
20
Q

Assessing risk and organ damage in hypertension

A
  • Fundoscopy: assess for hypertensive retinopathy
  • 12 lead ECG: ischaemic changes and evidence of LVH
  • Albumin: creatinine ratio and urinalysis: for underlying renal dysfunction
  • Bloods: HbA1c, U&Es, total cholesterol and HDL cholesterol

Assess cardiovascular risk

  • QRISK: estimates risk of a myocardial infarction or stroke over thee next 10 years
21
Q

Define white coat hypertension

A

Discrepancy of ≥20/10mmHg between the clinic reading and ABPM

22
Q

What is malignant (accelerated) hypertension?

A
  • BP ≥180/120 mmHg
  • Retinal haemorrhage and/or papilloedema
  • Target organ damage

Refer to emergency department

23
Q

Management of hypertension: Lifestyle modification

A
  • Improving diet
  • Reducing caffeine
  • Smoking cessation
  • Reducing alcohol consumption
  • Regular exercise
  • Low salt diet (less than 6g/day, but ideally 3g/day)
24
Q

Following ABPM or HBPM, which patients would you offer medication to treat hypertension?

A
  • ≥135/85 mmHg = Stage 1 hypertension
    • Treat if: <80 years AND
      • Target organ disease
      • Diabetes
      • Establised cardiovascular disease
      • Renal disease
      • QRisk ≥10%
  • ≥150/95 mmHg = Stage 2 hypertension
    • Treat all patients regardless of age
25
Q

Target blood pressure when treated hypertension

A
  • If <80 years old: aim for <140/90mmHg
  • If >80 years old: aim for <150/90 mmHg
  • If CKD: aim for <140/90mmHg
  • If CKD and DM: aim for <130/80mmHg
26
Q

Monotherapy options for hypertension

A
  • Aged <55 years OR T2DM (of any age)
    • Offer an ACE inhibitor (ACEi), e.g. ramipril
    • If intolerant to an ACEi, such as due to a cough, offer an angiotensin receptor blocker (ARB) instead, e.g. losartan
  • Aged ≥55 years OR African or Afro–Caribbean (of any age)
    • Offer a calcium channel blocker (CCB), e.g. amlodipine
    • If intolerant to a CCB, such as due to peripheral oedema, offer a thiazide-like diuretic instead, e.g indapamide
27
Q

Second and third line management of hypertension

A

Second-line:

  • If on an ACEi or ARB for step one: add a CCB or thiazide-like diuretic
  • If on a CCB for step one: add an ACEi, ARB or thiazide diuretic
    • ARBs are preferred over ACEi in African or Afro-Caribbean patients

Third-line:

  • Triple therapy: combine an ACEi (or ARB) with a CCB and thiazide-like diuretic
28
Q

Fourth line management of hypertension

A

Quadruple therapy: dependent on potassium levels. If hypertension is not controlled with 4 drugs, then consider a specialist review.

  • If K+ >4.5, add an alpha- or beta-blocker
  • If K+ ≤4.5, add an aldosterone antagonist such as spironolactone (a ‘K+ sparing diuretic’)

4th Year Cardiology (12 decks)

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